2. A bit of note
● Technique : mercury sphygmomanometer
● BP should be measured in both arms -
higher reading is taken as the systemic BP.
● BP should be taken both lying + standing to
detect any postural drop, especially in DM
and HTN the elderly.
● ?postural hypotension : Rising – Lying BP
>20mmhg
3. Non pharmacological RX
1. BMI:
- [Weight (kg)/Height 2(m)]
- Normal range :18.5 to 23.5kg/m2 .
2. Salt intake :
- ¼ teaspoonfuls of salt or 3 teaspoonfuls of
monosodium glutamate
3. alcohol : Standard advice is to restrict intake to no
more than 21 units for men and 14 units for women
per week (1 unit equivalent to 1/2 a pint of beer or
100ml of wine or 20ml of proof whisky
4. 4. exercise :
- “milder” exercise, such as brisk walking for 30 –
60 minutes at least 3times a week
5. diet :
-fruits, vegetables and dairy products
- reduced saturated and total fat
6. smoking cessation
5. When to start RX?
● Individual -patient’s global CVD risk.
● In diabetes mellitus or chronic kidney
disease, medical treatment is required if BP
is above 130/80 mmHg
● High risk subjects ( previous CVA or CAD)
the threshold for commencing hypertension
treatment should be lowered
6. Severe HTN
1. Hypertensive urgencies :
- Initial treatment should aim for about 25% reduction
in BP over 24 hours but not lower than 160/90 mmHg
2. Hypertensive emergencies :
- The BP needs to be reduced rapidly.
- 25% depending on clinical scenario over 3 to 12
hours but not lower than 160/90 mmHg
●
** why we cannot lower BP fast ?
Avoid renal / cerebral / coronary ischemia
7. HTN urgencies
- grade III or IV retinal changes , but no overt
organ failure.
DRUG DOSE ONSET of
action( hr)
DURATI
ON (hr)
FREQUE
NCY (hr)
CAPTOPRIL 25mg 0.5 6 1-2
NIFIDEPINE 10-20mg 0.5 3-5 1-2
LABETOLOL 200-400mg 2hr 6 4
8. HTN emergencies
● Present complications eg ac heart failure,
ACS, coronary aneurysm, HTN
enchepalopathy, RF, SAH
1. IV Labetolol 50mg bolus / 1 minute , repeat every
5 minutes interval ( max : 200mg) to continue IVI
2mg/min
● 2. IV Hydralazine 5-10mg/ min repeat evry 20-
30minutes. Initial IVI 200-300mcg/ min , maintain
50-150mcg/ min
● 3. pregnancy :
● IV Labetolol 200mg in 50ml NS, infusion
4ml/hr
9. Acute hypertensive crisis @
pregnancy
1. IV hydrallazine (2.5-5 mg bolus, or
infusion)
2. IV labetalol (10-20 mg slow bolus over 5
minutes, or infusion)
3. oral nifedipine (10 mg stat dose), may be
used to lower the BP.185-186 (Level I)
Sublingual nifedipine is no longer
recommended.184 (Level III)
Diuretics are, in general, contraindicated as
they reduce plasma
10. HTN and DM
1) Start Rx early in DM >130 mmHg and/or >80 mmHg
.Target to <130 mmHg and DBP <80 mmHg.
2) UFEME : proteinuria
urine microalbumin creatinine : microalbuminuria
→ treat even if the BP is not elevated. Use ACEI or ARB
3) Proteinuria >1g/24hrs: BP target <125/75 mmHg
11. Why ACEi for DM?
● CVD and renal protective effects
● If an ACEI is not tolerated, an ARB should be
considered.
● Not toleratble ? Beta-blockers, diuretics or CCB
12. HTN and renal dss(NOT DM)
ACEIs +ARBs : reduce the rate of doubling of serum
creatinine and ESRD
1) Serum creatinine of ≥ 30% from baseline within two
months, ACEIs/ARBs should be stopped.
● If serum creatinine of >200 mcmol/L
- 1st. loop diuretics ( 2nd. Thiazide )
- Loop diuretics act on the Na+-K+-2Cl- symporter
(cotransporter) in the thick ascending limb of the loop of
Henle to inhibit sodium and chloride reabsorption
2)Proteinuria
- CCB (diltiazem or verapamil) additional antiproteinuric
effect.
13. HTN and CV dss
● Post-infarction patients,
- ACEIs and BB especially in patients with LV
dysfunction, help to reduce future cardiac
events which include cardiac failure, cardiac
mortality and morbidity.
14. HTN and stroke
● Control BP effectively , HTN is a modifiable cause of
stroke
● Reduce mortality : BB, diuretics, CCBs, ACEIs and ARBs
-CCB ( better protection against stroke compared with
diuretics and/or beta-blockers )
● ACEI + diuretic - reduce stroke recurrence when
treatment was started at least 2/52 after the stroke.
● ARBs reduce morbidity and mortality from further strokes
compared to CCBs
●
15. HTN and elderly
● Rx , young VS old same.
● Standing BP should be measured to detect postural
hypotension
● Not tolerating treatment well? reducing SBP to below
160 mmHg acceptable
● Weight loss, reduce salt intake
● ACEi - concomitant left ventricular systolic
dysfunction, post myocardial infarction or diabetes
mellitus.
